Wisdom Wednesday: Acute Low Back Pain – A Brief Case History

This is the first in a series of typical case histories taken from my office notes. They will appear in the Wisdom Wednesday blog slot intermittently. I hope they will give the reader some insight into managing and guiding a patient through a health issue.

A 66-year old female returns to my office for the first time in six years with complaints of acute low back pain. She has been struggling with chronic bilateral knee pain and has had a couple of orthopedic opinions on treatment ranging from medication management to total joint replacement. She denies radiating pain from the back to the legs and believes the onset is related to compensating for the knee pain. She is currently on the following medications: Atenolol, Celexa, Benacar, Zyrtec, Eliquis, Prempro, Simustatin, Armour Thyroid, Flecainide and 2 baby aspirin per day. (The average American takes 4 prescription medications daily, so this patient is taking twice that amount. I commonly see patients taking 16 different prescription medications on a daily basis).

Autogenic Facilitation (AF) was intact, using a weak left gluteus medius as an indicator muscle. (This indicates no body wide injury response by the nervous system. Her body has either resolved the injury neurologically, or there was no body wide injury stimulation to begin with - the later fits her history) Oral challenge with a mix of NSAIDS resulted in strengthening of the weak muscle. A favorable response to oral challenge with fish oil was noted. (These tests indicate that her primary inflammatory response is the production of prostaglandins despite taking aspirin daily which tends to block this pathway) Challenge of the left ilio-lumbar ligament was positive in weight bearing only, corrected by Injury Recall Technique (IRT). (This is a local injury reflex and is the most common source of ongoing neurological stimulation in low back pain) Gait assessment was intact. (Despite her contention that this low back episode is the result of compensating for her knee pain, no altered gait mechanism was indicated)

Wisdom Wednesday: Ilio-Transverse Ligaments

The last six steps in the QA protocol involve assessment and treatment of the spine and extremities. This is the cornerstone of chiropractic care and most of you are familiar with spinal and extremity manipulation. However, the evaluation and treatment sequence of QA are what revolutionized my musculoskeletal practice.

Virtually every chiropractor has a core of patients with chronic low back problems. We treat these patients monthly, weekly, or sometimes even daily. In most cases, we are able to provide some measure of temporary relief. The patients are pleased because their pain has been reduced, but they are always vulnerable, seemingly going from one episode of back pain to the next.

My practice had that core. It was the most dissatisfying aspect of my job. All of that changed with QA. As soon as I learned how to reset the neurological patterns that drive most low back pain cases, my chronic patients began to stabilize. With their vulnerability resolved, activities of daily living – arising from bed, walking, sitting, bending and lifting no longer stimulated episodic low back pain.

The key is a pair of ligaments that attach the transverse processes of the L5 vertebra to the inner crest of the ileum bilaterally. Forty years ago, when I was a student, we were taught that the ilio-lumbar ligaments were comprised of proprioceptive fibers. That is, they sense position, and send that information to the brain. So if you are swinging a golf club, those ligaments tell your brain how the pelvis is rotating. However, we now know that only half of the fibers of the ilio-lumbar ligament are proprioceptors. The remainder are nociceptors – they elicit pain.

When stimulated, the ilio-lumbar ligaments send pain signals to the brain that result in low back spasm, restricted range of motion, and, of course, a sense of back pain. This is a protective reflex designed to prevent low back injury. However, when stimulated repeatedly, these ligaments fire spontaneously creating ongoing chronic low back pain and instability.

In my clinical experience, this neurological pattern of pain stimulation is the key factor in almost all cases of chronic low back pain.

Thirty-eight years ago, during my first year in practice, I quickly learned that if I could elicit pain on palpation of the ilio-lumbar ligament, that patient was not stable. Even if they were pain free at the time of examination, they would soon be back with another episode. Unfortunately, I just didn’t know how to correct the problem.

Four years ago, when I began to test and treat the ilio-lumbar ligaments, 95% of my chronic low back patients stabilized within 3-4 visits and no longer required constant care. The remaining 5% are victims of FBSS (failed back surgery syndrome) or have significant neuropathy that limits healing.

When patients have acute low back pain, these ligaments are typically firing constantly. However, in more chronic cases, the ligaments often fire only when the patient is seated as sitting increases weight bearing on the low back ten fold. In the worst case scenario, I can reboot this reflex with the patient lying on their stomach and it will fire again as soon as they sit up. Unless rebooted again while seated, the reflex will continue to fire and create low back instability. This is the patient that “never holds an adjustment” and returns repeatedly for treatment. However, when treated over the course of 3-4 visits, the threshold continues to rise, the ligaments fire less and less often, and eventually the low back stabilizes.

Clinically, I find little or no correlation between the degree of disc damage (herniation, protrusion, prolapse, or rupture) and the response to treatment. As noted previously, nerve damage and previous low back surgery are the significant limiting factors.

THE BOTTOM LINE:
If you suffer from chronic low back pain, please seek the help of a qualified QA practitioner. You can visit QuintessentialApplications.com to find a physician in your area.